Provider Demographics
NPI:1811059546
Name:GORE, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3990
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766
Mailing Address - Country:US
Mailing Address - Phone:808-240-0100
Mailing Address - Fax:808-245-8867
Practice Address - Street 1:4800 KAWAIHAU RD STE D
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1964
Practice Address - Country:US
Practice Address - Phone:808-240-0180
Practice Address - Fax:808-822-9298
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HICSDT-161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI523979-02Medicaid
HI0000258202OtherHMSA EAST
HICDST-16OtherHDS